For College Procedure 7.01.03.10: Immunization
Tuberculosis Testing and Physical Examination
Requirements for Health Career and Nursing Students
REPORT OF HEALTH EVALUATION
For Students in Health Occupations Programs
LAST NAME (PLEASE PRINT)
FIRST NAME
HOME ADDRESS (Number and Street)
MIDDLE
CITY
PROGRAM
STATE
DATE OF ENTRY
ZIP CODE
DOB
PATIENT’S HOME NUMBER:
CELL NUMBER:
EMAIL:
Heart Attack:
High Cholesterol:
High Blood Pressure:
Stroke:
Mental Health Dz:
Other:
Pets:
Indoor or outdoor
Please answer all questions. Comment on all positive answers below.
Have you had:
ENDOCRINE/METABOLIC
NAME, RELATIONSHIP, ADDRESS & PHONE # OF EMERGENCY CONTACT
FAMILY
Diabetes:
HISTORY Cancer:
Who do you live with:
PERSONAL HISTORY:
Have you had:
INFECTIOUS DISEASES
Measles
German Measles
Mumps
Chicken Pox (at what age)
Malaria
Tuberculosis
Mononucleosis
Hepatitis
Sexually Transmitted Disease
Other (Describe)
EYES/EARS/MOUTH
Gum or Dental Problems
Sinusitis
Eye Problems
Ear Problems
Throat Problems
IMMUNOLOGICAL
Hay Fever (Seasonal allergies)
Asthma
Allergies To: Medicines
Foods
GI AND GU DISORDERS
Frequent Nausea
Frequent Diarrhea
Constipation
Frequency of Urination
Burning on Urination
Gall Bladder Problems
Other (Describe)
NEUROLOGICAL DISEASES
Frequent Headaches
Dizziness or Vertigo
Head Injury/Unconsciousness
Epilepsy/Convulsions
Fainting
Weakness
Paralysis
Other
BLOOD DISORDERS
Clotting Disorder
Hemophilia
Leukemia
Anemia (Type)
Reviewed by:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Diabetes
Thyroid Problems
Other (Describe)
MUSCULO-SKELETAL
Disease or Injury of Joints
Arthritis
“Trick Knee”/Shoulder, etc.
Back Problems
Other (Describe)
FEMALES ONLY
First day of last menstrual period
Irregular Periods/Excess
Severe Cramps
Current Pregnancy
Other (Describe) G, P, A, L
CARDIO-PULMONARY
Shortness of Breath
Palpitations
Chest Pains/Pressure
Chronic Cough
High Blood Pressure
Rheumatic Fever
Heart Murmur
Recurrent Colds
Other (Describe)
MISCELLANEOUS
Tumors
Cancer
Cysts
Other (Describe)
PSYCHOLOGICAL
Mental Health Disorder(s)
Insomnia
Frequent Depression/Anxiety
Alcohol (ETOH)
Smoking
Recreational Drugs (cocaine/marijuana)
Miscellaneous
Surgery
Hospitalizations overnight
Major Accidents
Other (Describe)
CURRENT MEDICATIONS (List)
Y
Y
Y
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
Date:
EPCC does not discriminate on the basis of race, color, national origin, religion, gender, age, disability, veteran status, sexual orientation, or gender identity.
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A.
Has your physical activity been restricted during the past five years? YES
B.
Have you had difficulty with school studies or teachers? YES
C.
Have you received treatment or counseling for a nervous condition, personality or character disorder, emotional problems or
chemical/alcohol dependence? YES
NO
(Give details)
D
Have you had any illness or injury or been hospitalized other than that already noted? YES
E.
Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past five years? (Other than routine
checkups?) YES
NO
(Give Details)
Have you been rejected or discharged from military service or employment because of physical, emotional, or other reasons?
YES
NO
(If so, give reasons)
Do you have any learning disabilities for which you may require assistance? YES
NO
(Describe)
F.
G.
NO
NO
(Give reasons)
(Describe)
NO
(Give details)
I certify this personal history information to be correct:
Student (CLIENT) Signature
Date
TO THE EXAMINING PHYSICIAN/ADVANCED PRACTICE NURSE/PHYSICIAN ASSISTANT: Please review the student’s
history and complete the physical form. Please comment on positive answers. This information is for the use of the Health Careers Programs
and will not be released without student consent. Physician/Advanced Practice Nurse/Physician Assistant must be licensed in the United
States.
LAST NAME (Please Print)
Height
Weight:
Temp
Pulse
FIRST NAME
MIDDLE NAME
B/P
Resp.
IMMUNIZATIONS REQUIRED BY EPCC:
GENDER
Corrected/Non-Corrected Vision: R
O2 Sat on RA
L
% Corrective Lenses: Y/N Why
DATES
AGE
Both
How Long
(Immunization Record/Copy must be attached)
Varicella: 1st
2nd
OR Age of actual Illness
OR BLOOD TITER
Polio (3 doses up to age 19)
Measles, Mumps, Rubella: 1st_
2nd
OR BLOOD TITER
Tdap (Tetanus, diphtheria, pertussis) or Td (dose in past 10 years)
Tuberculin Skin Test (Chest X-ray, if indicated)
NEGATIVE
POSITIVE
Hepatitis B:
1st
2nd
3rd
OR BLOOD TITER
Other:
Physical Assessment
1. Head, Ears, Nose, or Throat
2. Respiratory
3. Cardiovascular/Blood
4. Gastrointestinal
5. Hernia
6. Eyes
7. Genitourinary (Males only)
8. Musculoskeletal
9. Metabolic/Endocrine
10. Neurological
11. Skin
12. Psychiatric/Emotional
Normal
Abnormal
Not
Examine
d
Comments
Recommendations for physical activity (including lifting, carrying, or standing) Unlimited/ Limited
Recommendations for accommodations for any learning disabilities, physical disabilities, or emotional disabilities Yes/No
(Explain)
General Comments:
EXAMINER’S SIGNATURE
ADDRESS
EXAMINER’S NAME and TITLE (typed or printed)
PHONE
FAX
EPCC does not discriminate on the basis of race, color, national origin, religion, gender, age, disability, veteran status, sexual orientation, or gender identity.
DATE
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